Healthcare Provider Details

I. General information

NPI: 1053418038
Provider Name (Legal Business Name): NORTHWEST ARKANSAS PERIODONTAL ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 N GREEN ACRES RD
FAYETTEVILLE AR
72703-2615
US

IV. Provider business mailing address

1831 N GREEN ACRES RD
FAYETTEVILLE AR
72703-2615
US

V. Phone/Fax

Practice location:
  • Phone: 479-521-6400
  • Fax: 479-521-0164
Mailing address:
  • Phone: 479-521-6400
  • Fax: 479-521-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY RENEGAR
Title or Position: MEMBER
Credential: DDS
Phone: 479-521-6400